Palliative Care Initiated in the Emergency Department: A Cluster Randomized Clinical Trial

Abstract

Importance: The emergency department (ED) offers an opportunity to initiate palliative care for older adults with serious, life-limiting illness.

Objective: To assess the effect of a multicomponent intervention to initiate palliative care in the ED on hospital admission, subsequent health care use, and survival in older adults with serious, life-limiting illness.

Design, setting, and participants: Cluster randomized, stepped-wedge, clinical trial including patients aged 66 years or older who visited 1 of 29 EDs across the US between May 1, 2018, and December 31, 2022, had 12 months of prior Medicare enrollment, and a Gagne comorbidity score greater than 6, representing a risk of short-term mortality greater than 30%. Nursing home patients were excluded.

Intervention: A multicomponent intervention (the Primary Palliative Care for Emergency Medicine intervention) included (1) evidence-based multidisciplinary education; (2) simulation-based workshops on serious illness communication; (3) clinical decision support; and (4) audit and feedback for ED clinical staff.

Main outcome and measures: The primary outcome was hospital admission. The secondary outcomes included subsequent health care use and survival at 6 months.

Results: There were 98 922 initial ED visits during the study period (median age, 77 years [IQR, 71-84 years]; 50% were female; 13% were Black and 78% were White; and the median Gagne comorbidity score was 8 [IQR, 7-10]). The rate of hospital admission was 64.4% during the preintervention period vs 61.3% during the postintervention period (absolute difference, -3.1% [95% CI, -3.7% to -2.5%]; adjusted odds ratio [OR], 1.03 [95% CI, 0.93 to 1.14]). There was no difference in the secondary outcomes before vs after the intervention. The rate of admission to an intensive care unit was 7.8% during the preintervention period vs 6.7% during the postintervention period (adjusted OR, 0.98 [95% CI, 0.83 to 1.15]). The rate of at least 1 revisit to the ED was 34.2% during the preintervention period vs 32.2% during the postintervention period (adjusted OR, 1.00 [95% CI, 0.91 to 1.09]). The rate of hospice use was 17.7% during the preintervention period vs 17.2% during the postintervention period (adjusted OR, 1.04 [95% CI, 0.93 to 1.16]). The rate of home health use was 42.0% during the preintervention period vs 38.1% during the postintervention period (adjusted OR, 1.01 [95% CI, 0.92 to 1.10]). The rate of at least 1 hospital readmission was 41.0% during the preintervention period vs 36.6% during the postintervention period (adjusted OR, 1.01 [95% CI, 0.92 to 1.10]). The rate of death was 28.1% during the preintervention period vs 28.7% during the postintervention period (adjusted OR, 1.07 [95% CI, 0.98 to 1.18]).

Conclusions and relevance: This multicomponent intervention to initiate palliative care in the ED did not have an effect on hospital admission, subsequent health care use, or short-term mortality in older adults with serious, life-limiting illness.

Trial registration: ClinicalTrials.gov Identifier: NCT03424109.

Figure 1.. Emergency Department Recruitment and Randomization and Patient Flow in Medicare Claims Data

^aThis cluster randomization included a stepped-wedge design. Randomization occurred between May 2019 and December 2021. There was a 6-month pause for the intervention between March 3, 2020, and September 14, 2020, due to the COVID-19 pandemic. The assessed Medicare claims data were from 2012 to 2022. ^bThe Gagne comorbidity score was calculated using the Romano adaption of the Charlson Comorbidity Index and the Elixhauser Comorbidity Index. The score predicts 1-year mortality. Scores range from −2 to 26; higher scores indicate an increase in mortality risk. The sample used a subset of patients with scores greater than 6.

Figure 2.. Hospital Admission Rates by Emergency Department Site and Intervention Period (Preintervention vs Postintervention)

Hospital admission is based on Medicare definitions. This category does not include patients assigned to observation status. The emergency department sites are ordered by intervention start date. The first site received the 3-week intervention in May 2019 with subsequent intervention rollouts planned every 3 weeks. The intervention rollouts were paused for 6 months because of the pandemic. The boxes are based on monthly hospital admission rates during each phase of the trial. Within the boxes, the line represents the median monthly hospital admission rates and the remainder of the box represents the first and third quartiles. The whiskers extend to upper and lower boundaries (1.5 × IQR). The lower hospitalization rate observed at emergency department site No. 25 may partly reflect underidentification of inpatient claims because visits at this site were identified using physician ID information due to the facility ID being shared across multiple emergency departments. The eFigure in Supplement 3 illustrates the hospital admission rates by month.